Individualized Physiotherapy of Upper Body Functional Movement Disorder – Two Illustrative Cases

Background: Information on specialist physiotherapeutic treatment for functional movement disorders is scarce. Previous studies focussed on functional gait disorders and availability of descriptions of the practical application especially for other body regions is very limited. Cases: We present two illustrative cases, demonstrating the key elements of physiotherapy for the treatment of functional movement disorders beyond gait difficulties. The individual applicability of the specific core elements of physiotherapy, adapted to the individual needs of each patient, are described. We also explain, how different sensory stimuli can be used to shift attention away from symptoms and thus reduce them. Moreover, we discuss how patients’ agency can be encouraged and how this results in therapy key moments, contributing to a sustained improvement of symptoms. Conclusion: Thus, our case series are intended to guide clinicians and therapists alike, to promote disease-specific physiotherapy for this common and treatable neuropsychiatric disorder.


INTRODUCTION
Functional neurological disorders are common and multiple neurological professions are engaged in their management [1].One of the largest subgroups of functional neurological disorders are motor/movement disorders.Despite their great heterogeneity, they are all characterized by inconsistency in severity and phenomenology under attentional refocusing.As a second diagnostic pillar incongruency to other non-functional movement disorders and neuroanatomical rules has been proposed.However, there is an intensive discussion whether this term should be avoided, as it might just be another way of making a diagnose of exclusion and requires omniscience in clinical neurology [2].Unfortunately, many patients are undiagnosed or have long diagnostic delays and thus receive no or delayed therapy, which is mostly unspecific [1].Based on the biopsychosocial model, functional movement disorders are multifactorial in origin, which makes it essential for the specific physiotherapy to identify individual factors.Predisposing vulnerabilities, e.g. in the biological context of an "organic" disease, in the sense of an emotional disorder on a psychological level, or in the social context of a specific life event or difficulty.Precipitation mechanisms, e.g. in the biological context of a physical injury/pain or e.g. in the psychological context of a life event perceived as negative and unexpected.Perpetuating factors are described in the biological context as plasticity in the motor and sensory pathways of the CNS leading to habitual abnormal movements and deconditioning, or in the psychological context as abnormal perceptions of illness [3].These factors influence the development and progression of the disorder and their processing helps to design a comprehensive and individualized therapy together with the patient.Therefore, specific physiotherapy follows a cognitive behavioral approach and differs from conventional neurological therapy concepts [3].Of note, specifically targeted physiotherapy is considered a first-line treatment [4,3,5] and greatly differs from conventional physiotherapy concepts for neurological diseases [1].However, only a few studies [3,[6][7][8] provided information on specific symptoms, e.g., functional tremor [7], but detailed descriptions and practical or real-world applications for the physiotherapeutic treatment of functional movement/motor disorders that go beyond functional gait disorders or affect the upper body are mostly missing.
For this reason, we here describe two illustrative cases demonstrating the applicability of previous findings and their adaptation to functional disorders other than gait disorders.

CASE SETTINGS
Based on two illustrative cases, we demonstrate how specific physiotherapy can be practically applied in an outpatient setting for patients with functional movement disorders of the face and upper body.Patients received between 10 and 20 treatment sessions, each lasting approximately 60 minutes.Core elements of the specific physiotherapy were adapted from consensus recommendations [3] and included 1) psychoeducation about the clinical picture to promote its acceptance and understanding, 2) redirecting attention to foster movement (re)learning by promoting automated movements and 3) establishing awareness of self-efficacy of symptom reduction.A detailed summary of the clinical and therapeutic characteristics of both patients is given in Table 1.

CASE 1 «EYES ON THE JUGGLE» BACKGROUND
A 21-year-old woman presented with weakness of eyelid opening and perioral jerks (Video 1a) since the age of 19 years.The diagnosis of a functional movement disorder was made at the age of 20 years.Before commencing specific physiotherapy, she was on sick leave from her job as a hearing aid acoustician for six months.She also stopped doing sports (fitness and yoga) as this had caused worsening of symptoms.Only during horse riding, an improvement of eyelid opening was observed by friends, which, however, was not perceived by the patient herself.

INTERVENTION
At the start of therapy, the patient defined her primary treatment goal as voluntary opening and controlling of her eye movements especially during sports activities and computer work.She was instructed about the clinical picture and possible improvement using the example of horse riding, which improved symptoms by redirecting attention.In a next step, we introduced juggling to the patient, which she always wanted to learn.Through its motivating, playful character it very efficiently redirected her attention away from the affected body regions (eyes, mouth).Initially, a schematic structure of juggling was instructed, e.g., throwing and catching one ball per hand and throwing from one side to the other (Video 1b).Juggling was performed in front of a mirror and videotaped, so the patient received direct visual feedback.Recognizing that she could reduce her symptoms by directing attention towards catching the ball was perceived as a key moment, i.e., as if she "flipped a switch in her head" and she felt empowered (Video 1c).In addition to her physiotherapy sessions twice a week, she practiced two times per week by herself.In the third week of treatment, she was symptom-free.From then on, she could manage her private and professional life without symptoms.Next, we gradually made juggling more difficult, e.g., using three balls, or juggling while standing on a wobble board, until the end of therapy (Video 1d & 1e).
In addition, we encouraged the patient to identify perpetuating factors, e.g., her working conditions.Thus, additional relaxation strategies such as grounding [5] and pacing [3] were practised.After further improvement of her performance and increasing confidence, the patient decided to resume her professional work and initiated regular fitness training and yoga in addition to her hobby of horse riding.
More than a year after the end of treatment, the patient is still symptom-free.She identified her stressful working condition as a disease perpetuating factor.Thus, she changed her job and recently started working as a horse caretaker.

CLINICAL AND THERAPEUTIC CHARACTERISTICS OF PATIENTS CASE 1 CASE 2
Main symptoms

CASE 2 «BACK TO SOCIETY WITH TOUCH AND HEARING» BACKGROUND
A 58-year-old woman was suffering for six years from postural and intention tremor of the left hand.The tremor was accompanied by fatigue and pain in the neck and shoulders.She quit her job, had difficulties performing household activities and could no longer pursue hobbies.
The tremor increased with conscious use of the arm or when trying to supress it (Video 2a).She realized that routine tasks not requiring much attention, e.g., cleaning herself in the bathroom, sometimes considerably ameliorated the tremor.Due to the variability of the symptoms and their rapid change she felt insecure during activities.Moreover, she had difficulty explaining her symptoms to her family and friends, which resulted in loss of social contact.

INTERVENTION
In the first sessions, the understanding of the clinical picture, its therapy, and the importance of conscious control of attention were discussed.The above-mentioned examples from everyday life were used illustrate the attention dependency of symptoms and their variability.
The patient quickly recognised additional triggering factors such as crowds and the associated inner expectation that "nothing will work anymore".Together we defined therapy goals as reducing the tremor during cooking and eating and being able to meet family and friends again.During the first treatment sessions, the patient realized that her tremor decreased when she focused attention on the texture of objects she was using, e.g., the perception of the texture of a cup when drinking or the handle of a knife when chopping.Sounds the patient could focus on when moving her arm were also helpful, e.g., her tremor decreased while concentrating on the sounds of the bubbles when drinking sparkling water.Focusing on rhythmic motor performance, for example when tapping her foot on the ground, was also helpful to gain control of her arm movements (Video 2b & 2c).The patient's own perception of the change was supported by video feedback to visualize the reversibility of symptoms.This was perceived as a key moment.Her self-confidence grew and she started to incorporate techniques she had learned into her daily life, e.g., while attending concerts and family celebrations.Moreover, she used the knowledge she gained about the disease to explain her symptoms to family members and friends, which had previously hindered her from meeting them.
Six months after the treatment, the patient was able to willingly control her tremor, even though the symptoms persisted in her daily life.It seemed that the patient only used her treatment strategies, when necessary, i.e., when the tremor appeared.Meaning that these strategies are used more as compensation rather than a consistent learning method to adapt motor control.At the same time, from the authors' perspective, this suggests an incomplete understanding of the illness and its therapy, as there was also a lack of engagement with potential disease-perpetuating factors in her daily life.

DISCUSSION
Our case series demonstrate that disease-specific physiotherapy in an outpatient setting is feasible and effective in patients with various functional movement disorders of the face and upper body.Such treatment differs from conventional physiotherapy applied for nonfunctional neurological disorders, with its core element being not to focus on dysfunction/ affected limbs.Thus, manual therapy or strength training, focussing on movement execution and control of the affected body region, are inefficient and can instead maintain and even worsen symptoms [3].In contrast, physiotherapy for functional movement disorders educates patients to control and redirect attention away from the symptomatic body part, thus reducing excessive pathological extrinsic control and fostering more automatic, intrinsic movements [3,5,4].For this purpose, at the beginning of our training, we analysed which stimulus quality, e.g., acoustic, tactile, or visual, helped the individual patient best to redirect her attention easily and effectively away from the symptomatic body region.
Moreover, our treatment comprised psychoeducation.We enabled the patients to realize that there are certain mechanisms in their daily life that alleviated their symptoms (e.g., hobbies) and included them in our treatment.Therefore, interests and personal preferences should be integrated into treatment sessions when designing individual therapeutic strategies.With the help of visual feedback (e.g., mirror, video), patients experienced their agency, which increased their selfconfidence and encouraged them to increase their training level, i.e., trying out new motor tasks.Patients reported key moments resembling turning points in coping with the disease.Importantly, patients described that our training not only reduced motor symptoms but also had, albeit less so, positive effects on fatigue, mood, concentration, and pain.
It is important to keep in mind that in our experience patients with functional movement disorders tend to over-perform once they notice symptom reduction.Newly gained control of action can lead to increased expectations, pressure, and stress, which in turn can result in relapses.In such situations focussing on psychoeducation is very helpful.Thus, the physiotherapist can enable the patient to identify disease mechanisms that might have contributed to the current symptom exacerbation and ensure that the patient fully understood the disease and its perpetuating factors.Moreover, including pacing, graded exercise, and relaxation strategies can help to better cope with psychological stressors [3,5,6,9].
Another aspect for relapse of symptoms could be that stimuli and training techniques became too trivial to effectively capture attention and require adaptation to keep the attention span high enough.Thus, a gradual increase of performance difficulty is recommended.
Our case series resemble two different responses to specialized physiotherapeutic treatment.The first patient totally recovered from symptoms whereas the second one used the treatment to temporarily suppress her symptoms.Thus, the latter patient continued to have symptoms especially when confronted with diseasetriggering factors during her daily life.It emphasizes that a central understanding and acceptance of the illness and its therapy are key mechanisms to achieve consistent symptom relief.Therefore, it is crucial to facilitate interdisciplinary exchanges with other disciplines involved in the treatment of the same patient.It is highly recommended to ensure a uniform treatment according to the same guidelines.A broad range of information and training for therapists and other healthcare professionals is needed to raise awareness of functional neurological disorders and to establish nationwide therapeutic services.

ETHICS AND CONSENT
Approval of the local ethic committee of the University of Lübeck, Germany was obtained for the study .Informed consent of all patients was obtained prior to inclusion of the study.We confirm that we have read the Journal's position on issues involved in ethical publication and affirm that this work is consistent with those guidelines.

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Personal key moment by recognizing the function in the video feedback • Motivated and informed to practice a home exercise training • Reflexion of everyday life • Recognition of the symptom triggers and their dependence • Personal key moment when recognizing the reversibility of the symptoms • Focus on directed attention with haptic and auditive stimulus e.g., texture of the knife handle when cutting, listening the bubbles when drinking, rhythmic foot tapping • Building self-confidence through symptom control, being back to society Goals pre-treatment • Voluntarily opening eyes: 10 min.sports 1-2 hrs.riding horse 1-2 hrs.computer work • Cooking, cutting vegetables without symptoms • Reviving social activities Goals post-treatment • 2-3 times per week fitness • Functioning at work • Attending concerts, exhibitions with more self-confidence and trust Video 2a.Pre-intervention.2b.Key moment during physiotherapy.2c.Post-intervention.

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Weakness of eyelid opening • Perioral jerks • Postural and intention tremor left arm

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Receiving disability pension since the age of 55

Table 1
Clinical and therapeutic characteristics of patients.
Video 1a.Pre-intervention.1b: Start schematic juggling (in front of a mirror).1c: Key moment during physiotherapy (in front of a mirror).1d: Progression in juggling.1e: Post-intervention.